Columns, Training

Incorporating Patient Safety Objectives into EMS Simulation Activities

Issue 10 and Volume 42.

We must respect the past, and mistrust the present, if we wish to provide the safety of the future.”
-Joseph Joubert (French essayist and moralist, 1754-1824)


There’s no doubt that in healthcare the goal is to perform safely: safe to the provider, safe to the patient, and safe to all those around us. This concept has been summarized into the term “patient safety.”

Many of the common definitions of patient safety focus solely on the patient. The Institute of Medicine states that patient safety is “the prevention of harm to patients,”1 while the Agency for Healthcare Research and Quality lists it as “freedom from accidental or preventable injuries produced by medical care.”2

Despite this focus on the patient, the role of the healthcare provider remains critical. The performance of the provider related to the care of the patient determines whether a patient, and all those involved with patient care, remain safe and free of harm.

EMS is a specialized patient service that functions outside of a controlled environment. Until recently, EMS education curricula have overlooked patient safety initiatives as a primary goal or an important aspect of EMS education.

In 2005, the Center for Patient Safety (CPS) was established as an independent, nonprofit organization dedicated to reducing medical errors. Much of the work of CPS focuses on creating a patient safety culture. A safe culture is a foundation concept that supports all healthcare activities at all times.

The CPS is unique to other patient safety entities in that it has an identifiable EMS focus, and has identified 10 safety goals that intend to reduce patient errors and improve provider safety. The goals address current trends and those expected to grow in the near future: airway management, bariatrics, behavioral health, crashes, medication mistakes, patient safety culture, pediatrics, provider mental health, stretchers and transition of care.3

A Culture of Safety

Many leaders turn to the airline industry as an easy example of improved safety culture. In the late 1970s, when airline crashes were occurring on a frequent basis, the industry went through an overhaul to ensure passenger and crew safety. Medical errors are the third leading cause of death in healthcare and EMS isn’t exempt from contributing to the abysmal statistics.4

Ultimately, a patient safety culture stems from the leadership of the organization. Frontline providers must also have an understanding and healthy appreciation for its importance. We need to shift our culture and attitude about errors and near miss reporting to understand the depth and breadth of the safety issues in EMS.

Some organizations have a punitive system in place in response to error reporting. This causes providers to enact “Vegas rules” while caring for patients in the prehospital environment. Transparency to capture an error or near miss errors is paramount to understand ing the factors affecting EMS patient safety.

Adding to the complexity of an EMS patient safety culture are shortcuts taken with the purpose of expediting care. Normalization of deviance is the term used when standards of practice modifies for perceived betterment.5 During the majority of patient interactions, this deviance doesn’t cause untoward outcomes and, over time, providers modify their systematic patient care routines to adopt these perceived better procedures. It’s only when used during an outlier or rare case that these shortcuts can lead to a patient safety concern or even a medical error.

Performing skills and procedures the way they’re supposed to be performed and repeatedly practicing these in a controlled education environment is one sure way to improve safety.

Simulation’s Role

During a simulation activity, patient safety is often an omnipresent focus and not identified as a single learning objective. This is especially true as learners move through curricula and become more experienced. Nevertheless, patient safety is a meta-objective that must be present in every simulation activity. (See our August column for more information on the concept of meta-objectives.)

For example, evaluating patient care during movement and ensuring therapeutic communication with patients is occurring includes a focus on patient safety. The specific objectives for the activity may not include safety for the provider or to the patient, but they are required and included as part of the exercise.

Too often, participants attend simulation sessions and talk their way through skills instead of physically engaging in the activity. This undermines the effectiveness of simulation and the necessary steps to promote a patient safety culture. It’s critical to have both novice and experienced participants perform skills as closely to the evidence-based standards as possible.

Consider assessing and debriefing how participants respond, react and are treated when an error or near error occurs. Developing a reporting mechanism to capture data from simulations that can help identify the area of focus for improved EMS patient and provider safety can only help improve our patient safety culture.

In our upcoming column (published in the December issue), we’ll identify specific patient safety objectives and demonstrate how simulation activities can be designed to support safety goals and help build and strengthen a patient safety culture for your agency. It’s important to embrace this important change in EMS philosophy to support the safety of our patients and our prehospital care providers.


1. Aspden P, Corrigan J, Wolcott J, et al., editors: Patient safety: Achieving a new standard for care. National Academies Press: Washington, DC, 2004.

2. PSNet. (n.d.) Glossary: Patient safety. Agency for Healthcare Research and Quality. Retrieved Aug. 27, 2017, from

3. Center for Patient Safety. (2016.) EMS forward: 10 topics that will move EMS forward in 2017. Retrieved Aug. 27, 2017, from

4. Bigham BL, Buick JE, Brooks SC, et al. Patient safety in emergency medical services: A systematic review of the literature. Prehosp Emerg Care. 2012;16(1):20-35.

5. Banja J. The normalization of deviance in healthcare delivery. Bus Horiz. 2010;53(2):139.